Do you have any convictions for any offence/s from any court, or are you currently the subject of any charge/s pending before any court? If yes, please provide details.

If yes, please provide details below:

If requested to do so are you willing to obtain a National Police Clearance?

Do you hold a current Drivers Licence?

Licence number

Licence type

Are you an Australian Citizen?

If not, what is your current residency status?

Visa type

Visa expiry

Skills

Achievements

Employment History

Qualifications

Medical

IMPORTANT: Failure to provide full and accurate information may result in the denial of any future workers’ compensation claim in accordance with Section 79 of the Workers Compensation and Injury Management Act 1981, as amended, which states: "where it is proved that the worker has, at the time of seeking or entering employment in respect of which he/she claims compensation for a disability, willfully and falsely represented themselves as not having previously suffered from disability, a dispute resolution body may in its discretion refuse to award compensation which otherwise would be payable.

Please tick the box beside any of the following items that apply to you:

Do you have any medical condition or injury that may pose a workplace risk to yourself or others?

If yes, please provide details below:

Do you have any pre-existing medical condition or injury that will, in any way, hinder your ability to perform the tasks of the position for which you have applied? If yes, please provide details.

If yes, please provide details below:

Are you required to take any medication that may affect or hinder your work performance?

If yes, please provide details below:

Do you suffer from any back, neck, shoulder or knee complaints that may affect your ability to perform the duties required of the position for which you have applied?

If yes, please provide details below:

Have you ever claimed workers’ compensation?

If yes, please provide details below:

Are you being treated by any doctor for any medical condition or illness?

Have you been hospitalised for any illness in the last year?

Have you had a Tetanus injection in the last 10 years?

Would you be willing to undertake a medical examination if required?

Would you be willing to undertake an alcohol and other drug test if required?

Please tick the box beside any of the following activities with which you have difficulty:

Hearing a normal conversation

Understanding English

Reading ordinary sized print

Standing for 2 hours

Sitting for 2 hours

Lifting or bending

Repetitive movements of the hands or arms

Gripping firmly with both hands

Kneeling

Crouching

Turning your head rapidly

Running 100 metres

Concentrating on what you are doing

Attachments

Declaration

I certify that the information supplied in this Employment Application is true and correct. I understand that false, misleading or non disclosure of information may result in possible disciplinary action including termination of employment.